A prescription for only a months supply of Levothyroxine. A challenge!

[1Georgina1]

I have recently changed to a GP surgery where they will only issue one months supply of Levothyroxine. Please could anyone tell me whether there are any statutory or government mandates concerning this practice. Thank you.

[SeasideSusie Remembering]

1Georgina1

Look at Related Posts (to the right on a PC, you may have to scroll down on another device). This has been discussed before.

I believe it may be down to each individual surgery.

My surgery will only give 4 weeks prescription for anything whereas years ago rather than a prescription for 28 days I could have 112 days.

Some members are restricted to the same amount as my surgery allows, others can have more.

[1Georgina1 in reply to SeasideSusie]

Thank you. I did see the relevant posts but they were from many years ago. I wondered if there was more up to date information.

[Hidden in reply to 1Georgina1]

I get a 2 month prescription. Which is still frustratingly short.

[jan95 in reply to Hidden]

I also get a 2 monthly prescription, always have done.

[SeasideSusie Remembering in reply to 1Georgina1]

There definitely are much more recent posts, I know it was discussed last year, maybe even earlier this year, but the search facility is so poor it's not easy to find them. Give it a try and see if you can. No idea what the best search term is though.

[J675]

Do you use Patient Access? I use it to reorder my meds every four weeks and it takes literally less than a minute to get my prescription request done.

[1Georgina1 in reply to J675]

I am in the process of setting up Patients Access with a new surgery. I have ordered on line previously which is handy for the ordering but does not get over the likelihood I am away when I need to collect the prescription and run the risk of running out!!! This problem is made more acute when issued only a months supply😱!

[SeasideSusie Remembering in reply to 1Georgina1]

When I went on holiday I used to ring the surgery, explain how long I would be away for, and asked if they would issue a prescription with enough tablets to see me over that amount of time. There was never any problem with that as a one-off.

[FancyPants54 in reply to 1Georgina1]

Just reorder about 5 days early each time (so basically every 3 weeks) it’s what I did. It meant I was able to get a month in hand quite quickly. Ordered by Patient Access straight to a pharmacy of my choice (not surgery) meant no one queried it. I have built up plenty of spare thyroxine now.

[helvella Administrator Thyroid UK]

For many years now, there has (in the UK) been a near-universal imposition of 28-day prescribing.

There is, quite simply, no rational basis for this policy in relation to long term medicines on repeat.

There is incoherency where we are told that we can only have a 28-day supply of a medicine even if it has been prescribed to be taken as needed.

There are the potentially severe consequences of running out of many medicines. For example, steroids, insulin, thyroid hormone.

Short prescribing, with the intention that we only apply for a repeat in the last few days, puts people at risk from supply issues, from other difficulties in getting their prescription issued (even as basic as distribution problems or just feeling ill).

For those who do not live near the GP surgery or pharmacy, there can be transport and time costs, sometimes considerable. This multiplies if the pharmacies do not have the product on their shelves, ready to dispense.

The major beneficiaries of 28-day prescribing of medicines which are prescribed long term seem to be to pharmacies. The specific claim that pharmacies are pushing for 7-day prescribing of MCA (multi-Compartment Aids) to recover costs rather supports that view.

We need pharmacies, pharmacies have to be viable, but effectively making work for them so they can increase their income seems entirely wrong-headed.

This imposes extra work on GPs and other prescribers. While this is always an issue, it is of particular relevance when there is a health emergency of any sort.

That if we are unlucky enough for the next repeat to fall at Christmas/New Year we clash with an already busy time where we are requested not to contact our GPs, if possible.

Those who impose and enforce 28-day policies are ignoring advice and research which questions its existence.

This includes the MHRA report on levothyroxine, published in 2013, where the CHM advised prescribing on a three-month basis. And more recent articles published by the British Journal of General Practice and the paper that used as a reference, the BMA, Pulse, and others.

I have included extracts from each below.

Prescription intervals

Doctors should provide prescriptions for intervals that they feel are clinically appropriate. This should take into account:

• possible reactions

• the stability of the treatment

• patient compliance

• necessary monitoring.

Sometimes a doctor may give six or even twelve months supply on one prescription as this is cost-effective and convenient for patients.

We have also received requests for GPs to consider shorter duration prescribing (28-day prescriptions).

Prescribing intervals can place significant workload on doctors and surgery staff, and should be in line with patients’ medical needs. Pharmacy requests to issue a seven-day prescription should be discouraged.

The request for seven-day repeat prescriptions to defray the pharmacist’s costs for the filling of MCAs has become an increasing pressure for GPs. Our advice is to resist such demands unless there is a clinical reason for restricting supply to seven days.

• Consistency of size, shape and colour of the medication could be more effective than using MCAs (can be confusing for patients).

• There are some storage problems involved in using MCAs, such as possible deterioration of drugs after being taken out of the packet.

• There are alternative ways to support patients taking medication, such as medicine advice charts, which allow the drugs to be retained in their packaging with advice sheets

The GPC supports the PSNC in that both pharmacists and dispensing doctors issuing MCAs should be properly reimbursed for the services they provide to patients.

bma.org.uk/advice-and-suppo...

28-day prescription lengths for people with long-term conditions should be reconsidered, say health research team

March 13, 2018

The widely adopted practice of issuing 28-day rather than longer duration prescriptions for people with long-term conditions lacks a robust evidence base and should be reconsidered, according to new studies published in Applied Health Economics and Health Policy and the British Journal of General Practice today. The research shows that considerable savings could be made by the NHS switching to longer prescriptions.

Over a billion NHS prescription items are issued each year by pharmacists in the community, at a cost of over £9 billion. Many of these medications are used for the management of long-term health conditions, such as diabetes or heart disease. Prescriptions for these medications are issued through the ‘repeat prescribing’ system. This allows patients to request a further supply of medicines without needing to make another appointment with their doctor. Local guidance by clinical commissioning groups in many parts of the country encourages GPs to issue shorter supplies of these repeat medications, partly to reduce wastage. Prescriptions are typically 28 days in length, but this policy has been questioned.

The study, led by RAND Europe in Cambridge and funded by the National Institute for Health Research, examined previously published studies that looked at this issue, dating back as far as 1993. The researchers found nine studies that suggested that longer duration prescriptions are associated with patients being more likely to take their medications (better so-called adherence). They also found six studies that suggested that shorter prescriptions might be associated with less wastage, although these studies were considered to be very low quality.

Longer prescription lengths do seem to be associated with patients taking their medicines more regularly.” – Dr Ed Wilson, Senior Research Associate in Health Economics

In related work already published in BMJ Open, the researchers undertook an analysis of 11 years of UK GP prescribing data. This found that any savings due to reduced waste resulting from issuing shorter prescriptions were more than offset by greater costs due to the additional work required by GPs and pharmacists. Longer prescriptions could save GPs’ time, which could in turn be used to increase time spent with patients. Savings to the NHS from lengthening all prescriptions for statin drugs alone (one of the most commonly prescribed medications) were estimated at £62 million per year.

And in the economic modelling study, published today in Applied Health Economics and Health Policy, the researchers have shown that if longer prescriptions result in better medication adherence, this could lead to improved health outcomes and, as a result, further reduced costs for the health service.

Dr Ed Wilson, health economist at the University of Cambridge’s Primary Care Unit and co-author, said “Our results show that in many cases, longer prescription lengths could both reduce administration costs and improve health outcomes. This is because longer prescription lengths do seem to be associated with patients taking their medicines more regularly. However, the evidence base is not perfect so any national change in policy for repeat prescriptions should be phased and needs evaluating fully to make sure we do see the benefits we expect.”

Dr Rupert Payne, from the University of Bristol’s Centre for Academic Primary Care and one of the study’s authors said: “This has been a contentious issue for many years. Our research shows that the current recommendations to issue shorter prescriptions have been based on a lack of sound scientific evidence. There is the potential for longer prescriptions to lead to important benefits, by improving patients’ adherence and thus the effectiveness of the drugs, lessening workload for health care professionals, and reducing inconvenience and costs to patients.”

However, Dr Payne also cautions that lengthening prescriptions could have undesirable consequences for pharmacists. “Community pharmacies receive a fee for every prescription they dispense. So simply switching every repeat prescription item from, for example, one month to three months, could result in a large reduction in pharmacy income. Therefore, although the NHS may save money, it could lead to a loss of pharmacy services. Changes to policy around the length of repeat prescriptions should also consider how pharmacies are reimbursed.”

Dr Sarah King, Research Fellow at RAND Europe and lead author of the study, said: “Currently, the UK Department of Health and Social Care advises that the frequency of repeat prescriptions should balance patient convenience with clinical appropriateness, cost-effectiveness and patient safety but does not specify a recommended period. Given our study results, CCGs and local NHS may wish to reconsider current recommendations for 28-day prescription lengths for patients with stable chronic conditions.”

References

‘Long-term costs and health consequences of issuing shorter duration prescriptions for patients with chronic health conditions in the English NHS’ by Adam Martin, Rupert A. Payne and Edward C.F. Wilson. Applied Health Economics and Health Policy. 13 March 2018

‘The impact of issuing longer versus shorter duration prescriptions – a systematic review’ by Sarah King, Celine Miani, Josephine Exley, Jody Larkin, Anne Kirtley, and Rupert A. Payne. British Journal of General Practice. 13 March 2018

phpc.cam.ac.uk/pcu/28-day-p...

Why it’s time to re-think guidance on 28-day prescriptions

13 March 2018

Health researcher Josephine Exley says there is mounting evidence that cutting ‘waste’ associated with long-term scripts may be a false economy

In England, the NHS spends over £9 billion each year on prescription medicines dispensed through hospitals and GPs, which is equivalent to 7% of its total budget.

Long-term treatments with medication often play a fundamental role in the clinical management of patients with stable long-term non-communicable conditions, such as diabetes, asthma and hypertension. In many cases, patients are provided with so-called ‘repeat’ prescriptions that are usually issued without the need for further consultations with the GP.

Guidance issued by the Department of Health recommends prescription lengths balance patient needs and good medical practice, while also considering NHS resources. To try to control the costs of unused or partially used medications – estimated to cost around £400m a year – local commissioning groups have encouraged GPs to shorten prescription length, typically to 28 days.

However, our study commissioned by the National Institute for Health Research shows that increasing the length of prescriptions for people with long-term conditions could result in substantial savings for the NHS.

Despite the link between longer prescription lengths and increased waste, the study found that switching to longer prescriptions could result in cost savings, as the biggest impact on cost was the time administrating repeat prescriptions. Identifying patients with particular long-term conditions and characteristics that could benefit from longer prescriptions would be a good start toward realising these savings.

A good example is antidepressant prescriptions. Ninety five per cent of these prescriptions are less than 60 days, but a previous study showed longer-term prescriptions could potentially save as much as £305 million. This means that providing longer prescriptions for just one long-term medical condition would negate a large proportion of the costs of ‘wastage’.

The latest study also suggests that longer prescriptions could be associated with improved medication adherence. Therefore, there could be clinical benefits to increasing the length of repeat prescriptions for patients with chronic conditions. This could result in further long-term cost savings due to reductions in the use of health services by patients.

Another factor that could impact the cost savings are the personal costs incurred by patients through the shorter prescription lengths. The current evidence does not include the time and travel costs of patients that have to travel to hospitals, pharmacies or GPs to pick up their prescriptions. If these personal costs were considered then there is likely to be further savings associated with issuing longer prescription lengths.

Furthermore, 28-day prescription lengths have been described as disempowering and a hassle that can cause anxiety for patients when they are running low, particularly when their ability to travel is constrained.

We still need to do more research on these potential associations, but the evidence available suggests that the policy on 28-day prescriptions does at least require a re-think. The argument that it saves on ‘waste’ has been shown to be questionable, with the costs associated with dispensing fees and prescriber time outweighing wastage costs.

The current evidence base does not support policies and guidance promoting shorter prescription lengths over longer prescription lengths. If anything, the significant cost savings to the NHS warrants a look at whether more patients with long-term conditions should be issued longer prescriptions.

Josephine Exley is a Centre for Evaluation fellow at the London School of Hygiene & Tropical Medicine and a former senior analyst at RAND Europe

pulsetoday.co.uk/clinical/c...

Long-Term Costs and Health Consequences of Issuing Shorter Duration Prescriptions for Patients with Chronic Health Conditions in the English NHS

• Adam Martin,

• Rupert Payne &

• Edward CF Wilson

Applied Health Economics and Health Policy volume 16, pages317–330(2018)Cite this article

Abstract

Background

The National Health Service (NHS) in England spends over £9 billion on prescription medicines dispensed in primary care, of which over two-thirds is accounted for by repeat prescriptions. Recently, GPs in England have been urged to limit the duration of repeat prescriptions, where clinically appropriate, to 28 days to reduce wastage and hence contain costs. However, shorter prescriptions will increase transaction costs and thus may not be cost saving. Furthermore, there is evidence to suggest that shorter prescriptions are associated with lower adherence, which would be expected to lead to lower clinical benefit. The objective of this study is to estimate the cost-effectiveness of 3-month versus 28-day repeat prescriptions from the perspective of the NHS.

Methods

We adapted three previously developed UK policy-relevant models, incorporating transaction (dispensing fees, prescriber time) and drug wastage costs associated with 3-month and 28-day prescriptions in three case studies: antihypertensive medications for prevention of cardiovascular events; drugs to improve glycaemic control in patients with type 2 diabetes; and treatments for depression.

Results

In all cases, 3-month prescriptions were associated with lower costs and higher QALYs than 28-day prescriptions. This is driven by assumptions that higher adherence leads to improved disease control, lower costs and improved QALYs.

Conclusion

Longer repeat prescriptions may be cost-effective compared with shorter ones. However, the quality of the evidence base on which this modelling is based is poor. Any policy rollout should be within the context of a trial such as a stepped-wedge cluster design.

link.springer.com/article/1...

Impact of issuing longer- versus shorter-duration prescriptions: a systematic review

Sarah King, Céline Miani, Josephine Exley, Jody Larkin, Anne Kirtley and Rupert A Payne

British Journal of General Practice 2018; 68 (669): e286-e292. DOI: doi.org/10.3399/bjgp18X695501

Abstract

Background Long-term conditions place a substantial burden on primary care services, with drug therapy being a core aspect of clinical management. However, the ideal frequency for issuing repeat prescriptions for these medications is unknown.

Aim To examine the impact of longer-duration (2–4 months) versus shorter-duration (28-day) prescriptions.

Design and setting Systematic review of primary care studies.

Method Scientific and grey literature databases were searched from inception until 21 October 2015. Eligible studies were randomised controlled trials and observational studies that examined longer prescriptions (2–4 months) compared with shorter prescriptions (28 days) in patients with stable, chronic conditions being treated in primary care. Outcomes of interest were: health outcomes, adverse events, medication adherence, medication wastage, professional administration time, pharmacists’ time and/or costs, patient experience, and patient out-of-pocket costs.

Results From a search total of 24 876 records across all databases, 13 studies were eligible for review. Evidence of moderate quality from nine studies suggested that longer prescriptions are associated with increased medication adherence. Evidence from six studies suggested that longer prescriptions may increase medication waste, but results were not always statistically significant and were of very low quality. No eligible studies were identified that measured any of the other outcomes of interest, including health outcomes and adverse events.

Conclusion There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions. UK recommendations to provide shorter prescriptions are not substantiated by the current evidence base.

bjgp.org/content/68/669/e286

The MHRA report on levothyroxine recommends three-month prescribing. When I asked for that (as a new patient at a new surgery) the doctor very much implied that the pharmacists wouldn't like it - she gave me two months.

Levothyroxine Tablet Products: A Review of Clinical & Quality

Considerations

07 January 2013

9. Levothyroxine should be prescribed and dispensed in quantities covering three months supply, where appropriate, in order to address issues of continuity of supply and also to improve convenience to patients.

gov.uk/government/uploads/s...

[tattybogle in reply to helvella]

thankyou for being brilliant

[1Georgina1 in reply to helvella]

Thank you for these reports one of which I had found, read and then lost! I just could not find it again till you answered my question so comprehensively. I will refer to it when asking the Gp if she can possibly increase the script to a two months supply. It is a matter of finances as the surgery, a small rural one, has a dispensary which is paid per script. As with so much in the medical world, money appears to be prioritised over the patients needs! Thank you.

[holyshedballs in reply to helvella]

Excellent work helvella . Do you mind if I copy and paste your work?👍👍

[helvella Administrator Thyroid UK in reply to holyshedballs]

Of course not! But thanks for asking. 😀

[Yasrash]

Hiya I only get A month supply as well I get 28 tablets every month of

Levothyroxine 50 micro grams

[DoeStewart]

Hi 1Georgina1 - It is most likely because the pharmacies don't like 2 or 3 monthly scripts. As they get a dispensing fee for each item they dispense. If scripts are 2 monthly then they only get 6 dispensing fees for it per year but monthly they get 12, of course as medicines are mostly packaged in 28's which is 4 weeks worth then the pharmacist actually gets 13 of these fees. I know when I worked in a pharmacy and the GP surgery started to give Levo in 3 month scripts, the pharmacist had a meeting with the surgery due to his loss of income.

[endomad]

My gp surgery often ran 7-10 days behind with prescriptions, it was a constant bone of contention. My t3 was 3 monthly from hospital, I had to phone 7 days in advance to make sure they had stock as it was 35 miles away.

[Babette]

The receptionist at my GP's surgery tried that one and said the directive came from the CCG to stop stockpiling. The CCG knew nothing about it. They also wouldn't issue the prescription a week before I ran out, which doesn't leave any time for supply problems (I'm on liothyronine) or delays in being able to get to a pharmacy. They all seem to think we work around NHS timeframes and don't have lives.

I had a chat with a friendly GP who said it wasn't a problem. My dose has increased, the receptionist didn't update the frequency, which left me short and I'm now back at square one. I'll have another chat with the GP the next time I speak to him.

[Bearo]

I receive monthly deliveries of Levo, and don’t have to reorder as the pharmacy knows it’s on repeat. This was fine until the pharmacy delayed delivery while waiting for another prescription item to come back in stock, so I ran out of Levo and had to go to the pharmacy to see why I hadn’t received the next month’s supply. Having explained they were waiting on my eye drops The counter assistant asked if I would like to continue to wait so that I could receive both items together. I said no, the eye drops weren’t important, please give me the Levo. I got the Levo but they deleted my eye drops from the repeat order going forward!

[MGid]

Hi, to make the process smoother , in terms of delivery etc and save you time, I suggest you enrol online with a pharmacy for eg I did with Lloyds pharmacy,, you place online order and they will collect the prescription and n your behalf from GP, and post the order home. Very convenient

[Fluffyjules]

Hi, I asked my GP and they changed it to quarterly so I get mine every 4 months. Unfortunately it doesn’t fit in with my chemists repeat prescription ordering system which can only cope with 2 months, so I just order my repeat myself. So it can be done x

[Dizzy444]

My surgery normally will issue for 1month, however when I tell them I’m going away for a few weeks, which I often do, they allow me to have two or three months supply.

[tattybogle in reply to Dizzy444]

as my grannie used to say .. 'there's more than one way to skin a rabbit' ..... if they ever try to get me on 1 month prescriptions , i'm going to be "working away for 3 months " 4 times a year .

I didn't mind too much changing from 3 months to 2 when i changed GP's .. but if they think i'm messing around getting a prescription (and a different brand!) every 4 weeks ,they can think again.

[Cica77]

Mine have to be monthly and because I need a certain brand, can be a nightmare. Panic I’ll run out etc.

[holyshedballs in reply to Cica77]

See my response below. There is no logical reason for you to only have 1 months supply.

[Miffie]

My surgery always gives 28 days of all medications, including diabetic meds which are even more important to me than missing a few days of levo occasionally. I re order online and collect when ready. If I am to be away or unable to collect then I contact and collect either double the month ahead or a one of repeat early. It’s not a problem. I arrange to collect seven days before I run out and that allows for the odd problem either collecting myself or arranging for someone else to do it. I cannot use on online pharmacy as I take one drug which needs signed for and also a refrigerator item. I appreciate your concern however you should be able to find a way around it. Good luck

[Batty1]

One month prescriptions is insanity and this is what happens when you allow the gov’t to put their hands on your healthcare, they mess it up.

[jgelliss in reply to Batty1]

Spot On.

[holyshedballs]

So far as I know there is no logical reason to restrict the amount of Levothyroxine given at anyone time.

I spoke to my surgery about this issue and advised them that it is more convenient for everybody if i had 3 moths supply at each prescription.

I said I work full time and it is an unnecessary imposition for me to take time out of my day every month to go to the pharmacy.

I said that going every month increases the risk of contact with a COVID sufferer.

I said that levothyroxine has a shelf life of:

>Three years from the date of manufacture (polyethylene containers and amber glass bottles)

>Two years from date of manufacture (blisters)

>Two years from date of manufacture (polypropylene containers)

medicines.org.uk/emc/produc...

I said that my blood levels are not monitored every month so there is no clinical need for the amount to be restricted to one month.

I said that I am not aware of a black market trade in Levothyroxine as there is in some opioids.

Given the above, there is no logical reason for the amount given to be restricted to 24 tablets each time and 3 months is perfectly good for me. A doctor's decisions must be logical according to the Bolitho case.

I got a 3 month supply.

I have recently noted that one of the doctors at my surgery has reduced the amount from 3 months to 2 months without consulting me. Off again to the surgery. Or another letter.

its the same doctor who unilaterally reduced my dose again with out consulting me.

Hope that helps.

[Timetraveler67 in reply to holyshedballs]

That’s interesting about the shelf life Because my levo only has 2-3 months left on it each time I get it I always check the sell by date. I thought that’s why they only gave me every month because it goes out of date quick.

[nellie237 in reply to Timetraveler67]

I don't know if pharmacies have discount stores where they can buy short shelf-life products........but I am wondering now. Mine always has about a year on it.

[helvella Administrator Thyroid UK in reply to Timetraveler67]

My levothyroxine almost always has between one and two years to expiry - usually towards the top end.

[tattybogle in reply to Timetraveler67]

mine , (collected 3 weeks ago ) has 04/22 and 07/22 on it. I don't always check but whenever i have it's about this long.

[Minimol]

I found a prescribing guidance for nhs scripts that specifically referenced thyroid medication and used that to persuade my gp practice to issue 3-months of Levo at a time. I can’t find it now but will keep looking ....

[MCDW]

My practice gives me 2 month supplies, but I often order well in advance (because I travel a lot) and have built up some additional supply.

[Marymary7]

Mine only gives me 28 days which is so inconvenient. Reading Rod’s useful references if the doctor/NHS saves time and a lot money giving 3 months drugs out but the pharmacy looses the further 2 payments why don’t they agree to 3 dispensary payments in one go and its a win win?! Common sense rarely comes into it.

[holyshedballs in reply to Marymary7]

NHS internal markets I believe.

[FancyPants54]

I get mine one month at a time. It’s not a problem. You will get into a routine.